The Ethics of Bioethicsby Yves Englerwww.dissidentvoice.org
April 6, 2004

There
seems to be a single question driving bioethics today, a question that never
considers alternatives, never doubts whether or not to proceed with medical
technologies, but rather focuses its agenda specifically on how best to
proceed. . . ethically, that is, of course.

With the medical industrial
complex expanding rapidly this is something that should concern us. Already
U.S. health expenditures are the size of France's entire economy. Canada’s
health bill recently reached a tenth of the economy. Around the world
medicine is seen as an "economy of the future."

This expansion means a lot
of money to some big companies. Similarly a lot of doctors and scientists
have economic and status stakes in this medical expansion. Yet who does the
consumer -- often allowing her/his body to be "worked on" -- have to rely on
for protection? Bioethics. (There is also individual decision making, though
this is complicated by the power society defers to the medical establishment
and the medical establishment’s control over medical knowledge. Government
can also play a role, however, rarely do they perceive it in their best
interest to regulate (high-status) doctors or scientists.)

Yet can bioethics be
trusted to keep the medical industrial complex in line?

Probably not considering
how reliant bioethicists are on the medical industrial complex for funding.
Carl Elliot, author of
Better Than Well, writes “bioethicists at the University of Toronto
take funding from GlaxoSmithKline, Pfizer and Merck to write editorials on
bringing biotechnology to the developing world . . . the University of
Chicago’s MacLean Center for Clinical Medical Ethics co-sponsored a recent
conference with Pfizer, Merck and PhARMA, the pharmaceutical industry trade
organization, on inequities in American health care. . . bioethicists at the
University of Pennsylvania take money from Pfizer to write an article
explaining why physicians should not accept gifts from companies like
Pfizer. We may take industry money, bioethicists argue, but we’re not
industry stooges. We’re doing God’s work.” (Ottawa Citizen, Jan 2, 2004)

It appears, however, that
their function within the medical industrial complex is less than holy.

After the approval of the
drug Xigris in 2001, the drug’s manufacturer Ely Lily became disappointed
with sales of a drug it expected to be a blockbuster (1$ billion in annual
sales). Xigris is extremely expensive and evidence of its efficacy
inconclusive. Hospital doctors “concerned that insurance companies were
reimbursing the hospitals far less than the cost of the drug,” rightfully
hesitated to prescribe it. (Guardian Weekly, Feb. 19, 2004) So “in October
2002 Lilly created the ‘Values, Ethics & Rationing in Critical Care Task
Force’ (VERICC) with a $1.8 million grant.” VERICC, according to its Web
site, “is an independent, multi disciplinary research initiative dedicated
to the study of Intensive Care Unit (ICU) rationing practices, attitudes and
behavior among U.S. critical care physicians, nurses and hospital
administrators.” As Raymond De Vries asks “what better way to respond to
caregiver concerns about cost and efficacy then to label their unwillingness
to use a drug as unethical?” (G.W., Feb. 19, 2004)

We don’t yet know what
VERICC will find although already VERICC refers to protein C -­ the generic
name for Xigris -- as a “life saving medication ranking high on the
'to-be-rationed' list.” Certainly Ely Lily can expect even more for its
money than that not so subtle promotion for Xigris once VERICC’s findings
are published.

Lily seems to be especially
fond of using bioethicists when it has troubles. In 1996, “after the Wall
Street Journal reported that Lily was routinely using homeless alcoholics as
healthy volunteers for Phase 1 trials of new drugs” (G.W., Feb. 19 2004),
Lily turned to bioethicists to help its image (The report made Lily appear
unscientific since “tests for toxicity can be compromised by livers that
have processed too much alcohol” and Lily appeared cheap since they paid
“subjects the lowest per diem rate in the industry.”). “The company [Lily]
assembled a team of bioethicists drawn from some of the most prestigious
American bioethics centers to investigate the ethical issues associated with
the use of homeless persons in drug testing.” The bioethicists concluded “it
is not unethical or exploitative to use homeless people in phase I studies
if the system of subject selection is fair, consents are well informed and
bona fide, and the risks are not exceptional for the pharmaceutical
industry.” (G.W. Feb. 19, 2004) While this issue is certainly tricky,
doesn’t the desperate state of a homeless person make it difficult for them
to give bona fide consent? That’s the logic applied to prisoners who are
rarely allowed to participate in research. Ultimately Lily got what it
wanted from the bioethicists.

Questioning bioethics
relationship with the pharmaceutical industry more generally, Carl Elliot
asks “do bioethicists really want to brand themselves with Pharma? To take
only one example: the pharmaceutical sponsors of the University of
Pennsylvania Center bioethics and its faculty’s projects are now facing
multi million dollar fraud sanctions (AstraZeneca), a Nigerian lawsuit for
research abuse (Pfizer), massive class action payouts (Wyeth-Ayerst), a
criminal probe into obstruction of justice (Schering Plough), an ongoing
fraud lawsuit (Merck and Medco), and allegations of suppressing research
data on suicide in children (GlaxoSmithKline).” (Ottawa Citizen Jan 2 2004)
Not exactly the most ethical partners.

It’s not just the
pharmaceutical industry that uses bioethicists for direct self-serving
interests. Recently the American College of Obstetricians and Gynecologists
(ACOG) sought out a ruling from their bioethics committee on whether an
obstetrician should “agree to a mother’s request to deliver a baby by
C-section if there is no medical reason for the surgery”. (G.W. Feb. 19,
2004) The reason for the ethics review was that “in 2002, more than 25
percent of babies born here [in the U.S.] were delivered surgically. Nearly
all other industrialized nations have cesarean rates between 12 and 18
percent.” (G.W. Feb. 19, 2004)

ACOG’s ethics committee
concluded: “the decision on whether to perform an elective cesarean delivery
… will come down to a number of ethical factors including the patient’s
concerns and the physicians understanding of the procedures risks and
benefits. In the case of an elective cesarean delivery, if a physician
believes that cesarean delivery promotes the overall health and welfare of
the woman and her fetus more than does vaginal birth, then he or she is
ethically justified in performing a caesarean delivery.” (G.W. Feb. 19,
2004)

Sounds nice, however, the
problem with the ethics committee’s review is that it should never have
taken place. ACOG’s should have had its committee on obstetric practice make
the decision based on medical data not its ethics committee where there is
no "right" answer. While ACOG claims American women “believe that the
[C-section] surgery will prevent future pelvic support or sexual dysfunction
problems” the reality is that “recent evidence based guidelines developed by
Britain’s National Health Service suggest that it is surgical [not vaginal]
birth that is to be feared. The guidelines list a number of problems
associated with the procedure, including increased risk of hemorrhage,
infection, injuries to the bladder and urinary tract, and reduced
fertility.” (G.W. Feb. 19, 2004)

Not, “coincidentally,
ACOG’s pronouncement gives physicians’ the freedom to use a procedure that
is in their best interest: C- sections allow doctors to better schedule
their hours in the clinic, and they are reimbursed at a higher rate than for
vaginal births.” (G.W. Feb. 19, 2004)

Considering its history,
the hand-in-glove relationship of bioethics with the medical industrial
complex is no great surprise. Contrary to popular conception, bioethics does
not have its roots in outside hostility to the direction of the medical
scientific community but rather from within the scientific community itself,
as a tool to blunt public weariness towards technology and science.

According to Tina Stevens
in
Bioethics in America, “Bioethics caution toward medical and
scientific advances grew out of concerns first expressed by the postwar
bioscientific community. Among those scientists influenced by the atomic
science movement was a small but influential group of international
geneticists concerned with what they believed to be a ‘biological
revolution’. When the claims and fears of these geneticists became public,
some intellectuals in the United States became alarmed. This alarm helped to
call forth the growth of bioethics.

“Genetic discoveries during
the 1950s and 1960s were interpreted by their founders as unprecedented and
morally challenging. The geneticists believed that the public must be made
aware of their implications. Referencing the Atomic experience in their
calls for interdisciplinary scrutiny of biomedical research and development,
geneticists followed consciously in the footsteps of the post war
‘responsible science movement’, which had called for greater thoughtfulness
about the regulation of atomic power. It was an expanded interpretation of
‘the biological revolution’ that elicited the public response and helped to
provoke bioethics into existence. Although the world had been unprepared for
the atomic age, it was incumbent upon scientists, geneticists believed, to
prepare the world for the biological revolution, especially for its eugenic
implications. Should this responsibility be ignored, geneticists would not
only be morally culpable but could ultimately lose control over the course
of their research as well.” Losing “control over the course of their
research” was the motivating factor.

As part of the
anti-establishment feelings in the late 1960s there was a significant
radical current within bioethics that questioned the medical scientific
communities direction. However, quickly this bioethics current was either
marginalized or co-opted -- through money, prestige, etc. -- into the
service of the medical industrial complex’s ascendance. Questions such as
"should we do it" were replaced with "how can we do it" (ethically of
course). Jon Merz writes about the situation today: “Although research
ethics committees are charged with decisions on such important issues, many
fail in their role of protecting participants welfare and having sound
judgments about risks and benefits. They rarely reject proposed research,
often preferring to negotiate methods at the margins to resolve specific
ethical problems.” (Lancet, Jan 3, 2004) Rarely are the values underlying
the medical industrial complex challenged. Tina Stevens explains: “bioethics
was a more issue-specific, technology-by-technology enterprises than
historic ambivalence toward technoscientific advance. Bioethicists differed
from their radical contemporaries by focusing singularly on the products of
biomedicine, thus resisting claims made to larger connections between
science and society.” The “preeminent concern” was and is “to come to terms
with a new biology and technology.” Rarely are “power imbalances between
doctor and patient or between science and society” on the bioethicists’
agenda.

Likewise, Stevens writes,
“when bioethicists focused on non treatment decisions in neonatal intensive
care units, for example, ‘relatively little attention (is) paid to the fact
that a disproportionately high number of the extremely premature, very low
birth weight infants . . . are born to poor, disadvantaged mothers, many of
whom are single nonwhite teenagers’.”

Bioethics "reduces social
problems to fit within a framework that is utilitarian, positivist, and
reductionist.” In a similar vein, Leigh Turner writes “some of the favorite
topics of bioethicists seem trivial compared with the important health
issues facing people in the world’s poor countries and in impoverished
regions in rich countries.” (British Medical Journal, Jan 17, 2004)

Why aren’t more
bioethicists discussing the ethics of global health inequities? For
instance, “the risk of dying from maternal causes in sub Saharan Africa is 1
in 16. In Western Europe it is 1 in 4000.” (Lancet, Jan 3, 2004)
Bioethicists could focus their attention on the morality of a world system
that allows “500 000 girls and women [to] die every year - 99% in developing
countries - from preventable conditions and injuries related to pregnancy
and childbirth.” (Lancet, Jan 3, 2004) Certainly there is something
unethical about a medical industrial complex that puts loads of money into
Botox procedures while half a million women are dying unnecessarily.

These questions,
unfortunately, seem to be beyond the scope of mainstream bioethics. How
ethical is that?

Yves Engler recently finished his first
book, Playing Left Wing from Hockey to Politics: The Making of a Student
Activist.